Vasu Pai FRACS, MCh, MS, Nat Board Ortho Surgeon Gisborne

Vasu Pai FRACS, MCh, MS, Nat Board Ortho Surgeon Gisborne

FRACTURE MANAGEMENT I Simple closed fracture : Complete or Incomplete Stable or unstable II Open fracture III Multiple fracture IV Polytrauma

Fractures Incomplete: Greenstick Buckle [Torus] Tension force Axial compression Undisplaced (Except Hip) Non-operative treatment Displaced : Closed or Open reduction +/- Cast, Wires, Screws, Plates, Rods or External fixation

Role of traction Thomas splint Temporary splinting Bohler s splint.elevation of leg Plaster of Paris Cast in acute fractures Fibre glass cast after 10 days

Type III Supracondylar # Humerus

#NOF in an elderly person

DHS with Cannulated screw fixation

Split depression # of Lateral tibial plateau

Depression of the fragment

Extent of intra/extra articular #

3.5 Small fragment DCP with long screws

Maurice Muller Martin Allgower Hans Robert Willenegger

AO Principle 1958 (Algower, Muller, Willeneger) The AO center in Davos, Switzerland Anatomic open reduction Stable fixation Meticulous surgical technique Early mobilization Reudi (AO): 97% Union and 1% Inf. Others: 20-40% Delayed or Nonunion 6-10 Infection

Fixation Plating is a good procedure for NWB bones: Humerus, Radius & Ulna. Tibia and femoral shaft: IM Rodding

Intramedullary rodding Patient on the traction table

RETROGRADE NAIL WITH SPIRAL BLADE FIXATION

Intramedullary rod fixation Closed Intramedullary rods Gold standard for diaphyseal fractures of femur & tibia. 83 cases : Nonunion rate is 5% and 80% of cases healed in 3 months. 95% had good to excellent results at one year Pai 1998

Preop X ray Tibia *50 Y ; Female *Tripped on the steps (24/1/99)

Post operative X rays: ORIF 27/1/99- Classic AO fixation

4 months: Plate removed for infection

Established Non-Union (24/8/00) 2 cm shortening; 30* Varus angulation and 20* anterior angulation Ankle and subtalar: 70% of normal movement

MRI examination: Frank Non-union

Sept 00: Ilizarov ring external fixation

Classic fixation Vs Biologic fixation Small skin incision Less dissection Minimal vascular damage Early healing and high rate of union Reduces infection rate Havranek. Rozhl Chir 76: 359-63

Skin incision at medial malleolus Pai Int Orthop 2007

Tunnel is created Plate passed subcutaneous tissue

IMMEDIATE POST OP

Open fracture Anderson Grading Gustillo & I: <1cm ; Low energy;no soft tissue crush II: 1-10cm; Low energy;minimal STC III:High energy,comminution,significant STC a) Periosteum intact b) Periosteum stripped c) Vascular injury

Open fracture: Treatment Antibiotic, tetanus; splint, dressing Wound debridement and stabilisation +/- fasciotomy; Always: Wound open Repeated debridement Skin coverage

Type IIIa fracture tibia

Fracture at Middle with distal 1/3rd tibia

Fracture fixed with Hoffmans fixator

Rxed with EF and healed well at 6 months

Bilateral multiple feet #

Bilateral segmental comminuted L Open # femur R closed comminuted fracture

Open type III fracture

Grossly comminuted # distal radius

# R tibial plateau Bicondylar

Gardens III (R) & Post Dislocation L

C4-5 instability

Polytrauma : 4 periods: 1. Resuscitation period (0-3 hrs) 2. Primary stabilization period(3-72 hrs): Day-one surgery is performed 3. Secondary period (3-8 days) 4. Tertiary or rehabilitation period (>8 days)

Acute period (< 3hrs) *Circulation/Airway stabilization *Decompression of Organ cavities *Hemorrhage control *Pelvic clamp: 3% life threatening is due to H ge from Pelvis alone

Head Injury & Timing of skeletal fixation? Early or Delayed Advantages of early fixation Recumbency systemic Reduces the complications of traction & Reduces pain and decreases stimulus for a inflammatory response Easy nursing care Fracture outcome is better Decreases health care costs

Schmeling Clin Orthop 318: 106-16? Safe In patients with head injury, if hypotension and hypoxia are avoided, early fixation of long bone fractures does not increase the incidence of adverse cerebral complications

Surgical shock Not always represented by BP & Pulse Immediate crystalloid => Blood Platelets when < 50000 Frozen plasma: Hypofibrinogenaemia, Factor V and VIII

PRIORITIES: MUSCULOSKELETAL INJURY IN POLYTRAUMA 1. Concomittant vascular injury 2. Compartment syndrome 3. Open fracture 4. Closed fracture

Depressed # skull

Olecranon # Condylar #

Comminutted fracture femur (Closed)

Orthopaedic management: I Vascular injury II Compartment syndrome III Open fracture IV Closed fracture V Joint fractures

Priority of musculo-skeletal surgery *Limb salvage Vs Amputation: Mangled Extremity Scores: Shock Vascularity and Neurology Extent of injury Age

Biodegradable rods Lateral condylar fracture

Lateral condyle fracture: at 3 wks

Hybrid external fixator Indication: Complex fracture of proximal and distal tibia Wire fixation for the comminuted fragments and pins for the normal bone

# fixed with Wires; Replaced with Biodegradable rods

Post Op X rays: At 2 wks of EF : evidence of early healing by callus formation

Badly comminuted fracture distal end of tibia

Hybrid external fixator for intra-articular fracture of distal tibia

SUMMARY Management depends on Fracture morphology. No single method is applicable for all fractures Open fracture is surgical emergency. Early debridement and fixation is indicated. Polytrauma: Prioritization is essential

Intramedullary fixation of weight bearing bone - is a gold standard for Tibia and femur Minimally invasive technique is an useful technique in certain fractures Use of Biodegradable rods useful in children

Anatomical reduction is not always necessary. Alignment is more important.

Thank you